In the article discussing public health initiatives to combat obesity and their ethicality, Holm argues that there are three different forms of paternalism: hard paternalism (direct coercion), soft paternalism (giving unwanted information or foreclosing some options for action), and maternalism (control by inducing a guilty conscience). He then applies these types of paternalism to a discussion of the ethics behind obesity interventions. The first question is whether it is justifiable to promote a person’s own health or well-being, if they do not want intervention. I immediately thought of the ethicality of posting calorie counts at restaurants. If the person does not want the information, this is most definitely a form of soft paternalism, and even a little bit of maternalism as guilt may prevent someone from ordering what they want. But is it justified? 

Recent Studies 

Recent studies have found that while an estimated 15% of restaurant customers used calorie listings to help them choose healthier foods, the majority of listings were too confusing to guide diners to make healthier decisions.  Programs like these often encourage businesses to work towards putting healthier and more nutritious items on their menus as they know that customers will be provided with the nutritional facts in an easy and convenient way. For example, it is embarrassing for McDonald’s to have to disclose that 20 Chicken McNuggets is 860 calories. Thus this provides both an incentive for business owners to provide healthier alternatives as well for consumers to make healthier eating decisions.

Autonomous Decision Making 

Misinformation, along with busy lifestyles and too many unhealthy choices, has been pegged as one of the leading causes of the obesity epidemic. In order for consumers to make a fully autonomous decision based on informed choices, they must have enough information to do so. While it is likely that the calorie listings encourage people to make healthier decisions, the information provided is in no way biased. The calorie listings are simply stating the facts and thus I don’t think it is fair to view them as a bias or a source of forced paternalism. I think the main question is whether or not society or the state is justified in interfering in our personal choices. But is it really interfering if they are only helping us make a more well informed decision? I argue that no. The displays of calorie values are ethical as well as important to the health of our society.  There is no loss of freedom or autonomy in being provided the extra information, in fact autonomy is actually increased as more information allows one to form a better informed decision.

Humans have a natural rebellious nature because they feel entitled to control their own life. They do not wish for someone else to coerce them into doing something even if they feel that it is in their best interests. Instead, they wish to be given the chance to choose an action that is in their best interests.  When designing public health policy, it also best to limit coercion as much as possible because it will evoke more cooperation from the citizens.

Firstly, it is important to know that there are three forms of coercion: hard paternalism, soft paternalism, and maternalism. S. Holm describes hard paternalism as giving someone no option, soft paternalism as attempting to influence someone’s choice via manipulation of information, and maternalism as influencing someone’s decisions through guilt (Holland 392). Secondly, it is also important to know that no matter the circumstances, there will always be some level of outside influence on which decision a person chooses to make. The key is to make the person feel as if they have autonomously made the decision.

Obviously, hard paternalism can deter people from going through with a decision because they feel forced into their situation. D. Isaacs, H.A. Kilham, and H. Marshall assert that people “who are coerced into an action may be more likely to perceive the action as being risky than if they are persuaded into it (Holland 403). Essentially, when people are obligated to choose a default choice, they assume that there are underlying consequences that are not disclosed because these consequences will dissuade them from choosing that particular option. For instance, Simon Chapman argues that people are so hostile towards public cigarette smoking because they are forced to share the person’s toxic smoke. Nevertheless, people enjoy sitting around a warm campfire, where they, by choice, inhale its toxic smoke (Holland 408).

Meanwhile, the act of persuading, such as in soft paternalism and maternalism, forces one to unveil reasons why people should choose a certain option over other ones. This allows the person to feel that there are other options, but one particular choice is the best choice due to certain specifications. For example, educating people about the risks of obesity allows people to see that their life expectancy can be improved and their risk of disease can be lowered if they choose to diet healthily and exercise. Using soft paternalism, officials could lower insurance rates for those who live a healthy lifestyle. People still can choose to eat unhealthily, but it would not be in their best interest because they will have to spend more money to cater to a lifestyle that has been proven to shorten their lifespan. From a maternalistic approach, officials could inform parents that an unhealthy lifestyle could lead to a plethora of diseases such as asthma, diabetes, and heart disease that will lead to a poor condition of life as they grow up. Good parents should then feel guilty and thus decide to set a positive example for their children as well as ensure that their children follow this example.

Subsequently, compulsion may not be necessary in order to enact public health policy because simply giving the people an option will respect their right to choice, a key component of autonomy. One of the only instances in which compulsion may work is in a case in which a disease is immediately life threatening. This is because people value their lives and will do anything to preserve them, including subjecting themselves to mandated treatment. Still, people will view this mandate as a choice to do whatever it takes to save their life. In the end, people will comply as long as they feel that they are in control.

Sources:

Chapman, Simon. “Banning Smoking Outdoors Is Seldom Ethically Justifiable.” Arguing About Bioethics. Ed. Stephen Holland. New York: Routledge, 2012. 407-11. Print.

Holm, S. “Obesity Interventions and Ethics.” Arguing About Bioethics. Ed. Stephen Holland. New York: Routledge, 2012. 392-97. Print.

Isaacs, D., H. A. Kilham, and H. Marshall. “Should Routine Childhood Immunizations Be Compulsory?” Arguing About Bioethics. Ed. Stephen Holland. New York: Routledge, 2012. 398-406. Print.

The growing obesity epidemic raises concerns in many sectors from healthcare to the food industry and even the business sector, and S. Holm considers the place of ethics within these conversations about interventions to combat obesity. “Obesity Interventions and Ethics” brings up the controversial debate whether health is good for everyone, regardless of individuals’ values. Similar to the conversation about informed consent, obesity interventions involve a conflict of values between autonomy, respect for personal choices, and promotion of the common good.  Current policies such as the FDA’s forced phase out of trans fats by the food industry assume that being healthy is good for all citizens.[i] Governmental control on health and health decisions could be supported by the constitutional clause on promotion of general welfare. [ii] This argument of constitutional responsibility gives broad authority to the government to promote the general welfare, and in this context, general welfare could be seen as health. This sort of argument framework has been utilized in the debate on healthcare in the United States. Our nation is making a transition towards universal healthcare by enacting the Affordable Care Act. Therefore, our government is making claims that health is an important right and aspect of citizenship. Our nation is associating health with what is “good” and society members through payments and taxes are supporting this notion by merely being members of society.

In contemporary times, personal freedom is gaining emphasis as seen in the case of informed consent, and therefore, freedom surrounding people’s choices about their health and nutrition will be increasingly scrutinized.[iii] Current times will involve interesting interchange between personal freedoms and government promotion of health for all. There are nuances between government encouraging healthy choices and controlling the choices that society members make. For example, the FDA’s forced phase out of trans fats represents governmental control, or hard paternalism as defined by Finnish philosopher Heta Hayry. There is importance in Heta Hayry’s clever distinctions between the levels of paternalism: hard paternalism, soft paternalism, and maternalism, and these differing levels could be an important marker for evaluating public health policies. Soft paternalism and materialism are the most favorable because these still allow for pursuit of personal choice.  A health campaign out of Hawaii, “Rethink Your Drink,” cultivates repugnance in soda drinkers by using controversial advertising techniques.[iv] This matneralistic  method is more favorable in terms of the consumers’ freedoms and adherence and compliance. In comparison, Mayor Bloomberg’s proposed ban on sugary drinks which was seen as an overstep of power and was not passed due to its hard paternalistic nature. Instead of instilling empowerment and change, the law was challenged and ended in a victory for soda drink makers.[v] In context to the national assumption of health as good as mentioned previously, then I do believe that these acts of soft paternalism or maternalism are justified.

I think Holm’s article makes a good point about soft paternalism and maternalism but I think there needs to be a parallel focus on issues of accessibility and affordability for good health options and information. Quality interventions should deal with these aspects, and only when these areas are covered can an individual bear all responsibility for his or her own decisions. Holm’s mentions the circular and continuous debate over who holds responsibility for the obesity epidemic. Analysis in context to the constitutional argument, the United States bears a portion of responsibility in the individual’s choice. Therefore, an appropriate and efficient intervention will need to ensure that options presented are affordable, accessible (in terms of both material items and information) as well as not presented in a controlling manner.  Environment has a huge influence on how people make decisions, and soft paternalism or maternalism interventions can only initiate movement for change if certain things, such as food options, are available or affordable or else these interventions are in vain. The “Rethink your Drink” campaign was a success because the means for the campaign are available to all—cutting out sugary drinks and replacing them with water.

Thus, in order for a soft paternalistic or maternalistic intervention to be a success people need to have the means to follow through with the behavioral changes and from there on out, the responsibility lies in the hands of the consumer. As with discussion about informed consent, from this point there needs to be respect for the consumer’s decision, especially in this ideal intervention method.  While I believe these other aspects of the intervention technique are possible, I think respect will be the largest issue in applicability. Holms highlights this issue through conversation about stigmatization; respect is difficult to cultivate when people misunderstand other’s choices and tradeoffs or an individual’s sense of well-being.

Libertarian Paternalism: Helping Guide People in the Right Direction

Libertarian paternalism captures the combination of behavioral economics and paternalistic guidance.  Thaler and Sunstein define libertarian paternalism as guiding people to make an ideal decision without coercion or force.  A shortcoming of this concept is that many people falsely assume: 1.) there are viable alternatives to paternalism and 2.) paternalism always involves coercion (Thaler, Sunstein 386).  In the following paragraphs, I am going to refute these assumptions with demonstrations of necessary paternalism.

Firstly, libertarian paternalism can be well portrayed in the example created by Thaler and Sunstein in Behavioral Economics, Public Policy, And Paternalism: Libertarian Paternalism.  In summary, a cafeteria director realized that the order in which his food was arranged influenced consumer decisions.  So, what should the director do in order to change this problem?  This is when the concept of paternalism comes into play.  He could arrange the food so the healthiest options are more likely to be chosen, he could do the exact opposite, or he could choose randomly.  The director clearly has to make a choice here, so there are no other viable alternatives to paternalism.  Also, the director choosing the first option makes the consumers better off, without actually forcing any change in behavior (Thaler and Sunstein, 386).  Therefore, both false assumptions are not applicable to this situation.

Another example of libertarian paternalism is the program; Weight Watchers, which helps overweight people shed pounds and become healthier versions of them selves.  Occasionally, caring family members sign an unhealthy member up for Weight Watchers without their actual consent.  Does this constitute coercion or libertarian paternalism?  I believe signing up a family member in need does not constitute coercion, because they stand the right to refuse service and Weight Watchers would only make the subject better off.  If the subject is at risk for heart disease due to his/her obesity, then there are no viable alternatives and both false assumptions can be refuted yet again.

Finally, the concept of libertarian paternalism is directly correlated to many of the extreme medical dilemmas we have discussed in class.  For example, the earlier discussion of autonomous patients who are unsure if they want to proceed with treatment correlates to a physician’s usage of libertarian paternalism (Brody and Englehardt, 285).  Since the physician has the patient’s best interest in mind and cannot use coercion, (at least in fully autonomous situations) he might try to lead the patient in the most beneficial direction.  Also, when a patient is on his/her deathbed, there are normally no other viable options; therefore, disproving the false assumptions.

Overall, libertarian paternalism should not be immediately viewed as coercive and not allowing for individuality.  The previous three examples demonstrated a non-forceful, paternalistic approach with no other viable options; therefore, I think libertarian paternalism is necessary in many situations.

Works Cited:

1.)    Thaler, Richard H., and Cass R. Sunstein. “Behavioral Economics, Public Policy, And Paternalism: Libertarian Paternalism.” Arguing about Bioethics. By Stephen Holland. London: Routledge, 2012. 386. Print.

2.)    Brody, Baruch, and Tristram Englehardt. “ReservesDirect Login.” ReservesDirect Login. Prentice-Hall, 1987. Web. 24 Mar. 2014. <https://ereserves.library.emory.edu/reservesViewer.php?reserve=563720>. 285.

          In defense of public health law, Lawrence O. Gostin argues for more spending on public health resources. He finds that over the course of history, society has promoted individualism at the expense of public health services (374). Gostin uses the recent threats of bioterrorism as a reason why we should be more concerned with introducing more stringent and uniform state and local public health laws. The article might have held even more weight had Gostin referenced the 1989 public health fiasco concerning the Reston virus. Today’s film industry seems to be in love with movie plots featuring deadly viruses that lead to quarantine and panic; however, these fictional tales we often see only in the movies do have some grounding in reality. Richard Preston, a writer for the New Yorker and best-selling novelist, knows all too well about the real possibility of viral outbreak in the U.S. In 1992, Preston published an article about the Reston virus scare, which originated in Reston, Virginia. The true story stems from disease research on primates. Monkeys are imported to the U.S. from all over the world and are lab testers for potential cures to deadly viruses. In 1989, a shipment of macaque monkeys was moved from the Philippines into the U.S., and strangely many of them began to die (62-65). After a series of misdiagnoses of what was affecting the monkeys, researchers came across a strain of Ebola that had never been seen before (73). This caused immediate panic within the facility as it was yet unknown how the discovered strain of Ebola would affect humans. Eventually it was found that while the virus was harmful to monkeys, it could not harm humans, though it can successfully reproduce in the human body (79). Overall though, Preston’s article shows the very real potential of fatal viruses making their way into the U.S.

          After the outbreak of the Reston virus, the Institute of Medicine published a paper about emerging infections and the growing threat of mutant bacteria (Preston, 80). Seeing how the Ebola virus and many other viruses cause fatalities worldwide should pressure the U.S. and individual states into taking greater care about health-scare preparedness. As Preston states in his article, “the presence of international airports puts every virus on earth within a day’s flying time of the U.S.” (62).  Just the existence of a potential for outbreak means we should be doing everything that we can to prevent it, as well as to prepare for it. As Gostin states in his piece, it is not about passing legislation that will necessarily work, but rather passing legislation that is stronger, better, and more effective than what we currently have (378).This means having to sacrifice some personal rights in the state of a public emergency. Without these precautions, we actually threaten the exercise of autonomy, as well as endanger human beings. So, it might be necessary to give up what we think of as individual rights in times of emergency, for the greater good of protecting future autonomy and individual rights.

Works Cited

Gostin, L.O. “Public Health Law in an Age of Terrorism: Rethinking Individual Rights and Common Goods.” Arguing About Bioethics. London: Routledge, 2012. 374-384. Print.

Preston, Richard. “Crisis in the Hot Zone.” The New Yorker. Oct. 26, 1992. 58-81.